(continued)
Health screenings and interventions
SERVICE
GROUP CRITERIA AND FREQUENCY
• Screening of children and adolescents ages 9–11 years and 17–21 years; children and adolescents with risk factors ages 2–8 and 12–16 years • All adults ages 40–75 The following tests will be covered for colorectal cancer screening, ages 45–75: • Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually • Flexible sigmoidoscopy every 5 years • Flexible sigmoidoscopy every 10 years + annual FIT • Double-contrast barium enema (DCBE) every 5 years • Colonoscopy every 10 years, including a follow-up colonoscopy, for when stool-based tests reveal abnormal results • Computed tomographic colonography (CTC)/virtual colonoscopy every 5 years – Requires prior authorization • Stool-based deoxyribonucleic acid (DNA) test (i.e., Cologuard, Cologuard Plus), annually
Cholesterol/lipid disorders screening 1
Colon cancer screening 1
Congenital hypothyroidism screening
Newborns
Critical congenital heart disease screening
Newborns before discharge from hospital
Contraception counseling/education (including fertility awareness-based methods); contraceptive products and services 1, 3, 4 Dental application of fluoride varnish to primary teeth at time of eruption (in primary care setting) Dental caries prevention Evaluate water source for sufficient fluoride; if deficient prescribe oral fluoride 1
Women with reproductive capacity
younger than 5 years
Children older than 6 months
Depression and Suicide Risk Screening Maternal depression screening
Adults; Adolescents ages 12–18 Pregnant and postpartum persons
Developmental screening
9, 18, 30 months
Newborn, 1, 2, 4, 6, 12, 15, 24 months. At each visit ages 3–21
Developmental surveillance
Community-dwelling adults ages 65 and older with risk factors
Fall prevention in older adults (including assessment of risk, individual and group exercise, and physical therapy)
Folic acid supplementation 1
Persons planning or capable of pregnancy
Women at risk, including those with a personal or family history of breast cancer, ovarian cancer, tubal cancer or peritoneal cancer, or an ancestry associated with BRCA 1/2 gene mutation • BRCA1/BRCA2 testing requires precertification Pregnant persons with no symptoms of diabetes, at 24 weeks of pregnancy or after
Genetic counseling/evaluation and BRCA1/BRCA2 testing
Gestational diabetes screening
Sexually active women age 24 years and younger and older women at risk
Gonorrhea screening
Ages 6 and older, including pregnant persons – to promote healthy weight status; individuals with risk factors for cardiovascular disease; behavioral health counseling while pregnant
Healthy diet and physical activity counseling
Hearing screening (not complete hearing examination)
Infants through age 21
12 months
Hemoglobin or hematocrit
Pregnant persons; adolescents and adults at risk
Hepatitis B screening
Adults ages 18–79
Hepatitis C screening
Adults ages 18 and older without known high blood pressure
High blood pressure screening (outside clinical setting) 2
HIV Preexposure Prophylaxis (PrEP) for prevention of HIV infection 1 HIV PrEP related services (HIV screening, kidney function testing, hepatitis B & C screening, pregnancy testing, sexually transmitted infection screening/behavioral counseling, adherence counseling)
Individuals at risk
= Men
= Women
= Children/adolescents
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